Enriching Careers in General Practice: Could the right contract improve morale?

Many general practitioners still blame the 1990 contract for the problems in general practice, claiming it has reduced morale to levels of the 1950s and 1960s. The contract was introduced to improve the quality of care and to provide some measures of standards, but the government failed to convince general practitioners that the contract was what the profession needed. Further change seems inevitable. Ideally a contract should improve efficiency, enable rationale planning, and ensure public accountability. This article gives the history of the 1990 contract and discusses changes which could be made towards reaching this ideal.

If the recent changes in general practice seem drastic, it is worth considering Ronald Gibson's recollection of the days leading up to the inception of the NHS. Gibson, a general practitioner, foundation fellow of the Royal College of General Practitioners, and later chairman of the BMA's council, described the feelings of “being just a pawn in a rather bewildering game, in which the rules were partly being dictated and partly made up from week to week. I doubt if any of us in general practice then fully realised how our discipline was to be isolated and denigrated.”1 After 1948 there were 27 wilderness years before the charter for general practice was drafted. Even after general practitioners entered the promised land of group practices, better premises, practice teams, higher income, and retirement pensions in 1966, murmuring and complaining continued.2

Standards rose in some practices but not in all. General practitioners continued to complain about trivial consultations,2 hospitals began to extend their empires into the community in “outreach” schemes and through open access clinics, and it was said that general practitioners had become less accessible.3 The BMA and Royal College of General Practitioners suggested ways in which general practice could be made …